Connect for Health Colorado
Appeals Process
Wednesday, December 11th, 2013
Reasons for Filing an Appeal
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When an individual receives their final eligibility determination
notice, they will be informed if they are eligible for APTC, CSR, or a
Catastrophic health plan. If eligible for these subsidies or the
Catastrophic plan, they will be informed of the amount of aid they
will receive.
Applicants and enrollees may appeal eligibility determinations with
which they disagree:
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APTC/CSR denied or determined incorrectly.
APTC/CSR amount determined is incorrect.
People included in household is incorrect.
Amount or type of income that was used to determine eligibility was wrong.
Denied or incorrectly terminated for coverage under the Colorado Young Adult
Plan.
Denied or incorrectly terminated for coverage under the Small Business
Marketplace.
Appeals involve legal rights and a specific process. Complaints in
contrast, are a form of feedback and while useful to the
organization, do not involve legal rights.
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Filing an Appeal
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Appeal rights will be provided in the final eligibility
determination notice and customers will have 30 days from the
date of the notice to appeal the Marketplace decision.
Individuals who want to appeal may do so online, by mail, by
fax, in person, or over the phone.
When filing an Appeal, it is preferable to use the Appeal
Request form. To find this form:
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Go to www.connectforhealthco.com
Get Started dropdown  Individuals and Families
Hit the “Shop Now” button
Scroll to the bottom of the screen and click on “Feedback”
Under the Appeals section, the Appeal form is available to download
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Preview of Appeal Request Form
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Appeals Process – Phase 1: Intake
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When a customer submits an appeal request form, the Office of
Conflict Resolution and Appeals takes the information from the
form, processes it, and logs it.
The Office verifies the information provided by the appellant to
ensure that all the information that is necessary to trigger an
appeal is provided.
The Office of Conflict of Resolutions and Appeals will send a
receipt of the appeal request to the appellant within five
business days of the intake.
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Appeals Process – Phase Two: Analysis
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The Office of Conflict Resolution and Appeals (Office) will
investigate the specifics of the appeal.
If the Office finds that the determination was incorrect based
upon review, the Office will correct the determination.
If the Office believes that the determination was correct, the
Office will contact the appellant and schedule an Informal
Resolution meeting.
If the Office believes that the individual should be eligible for
Medicaid (even though the appellant is only appealing their
APTC/CSR determination), the Office will reach out to the
Department of Healthcare Policy and Financing to collaborate
on the case.
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Appeals Process – Phase Three: Informal Resolution
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Informal Resolution is a process where the Office will attempt to
discuss the eligibility determination process with the appellant and
explain to the appellant how the APTC/CSR is determined.
The appellant does not have to participate in Informal Resolution.
It is optional.
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If the appellant pursues Informal Resolution, understands the determination, and
agrees to withdraw their appeal accordingly, the appeal process will end.
If the appellant pursues Informal Resolution, still disagrees with the
determination, they may proceed to a Formal Appeal.
If the appellant does not want to participate in Informal Resolution, they will
proceed to a Formal Appeal.
If the appellant does not respond to the Office’s request for Informal Resolution
within 15 business days of our request for Informal Resolution, we presume they
have opted out of Informal Resolution, and they will proceed to a Formal Appeal.
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Appeals Process – Phase Four: Formal Appeal
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Formal Appeal is a court proceeding.
The Office of Administrative Courts (“OAC”) will appoint an Administrative
Law Judge (“ALJ”) to adjudicate and decide these cases.
o This is a real court hearing.
The ALJ will render a decision within 90 days of the appellant filing the
appeal request form.
o If the ALJ agrees with the appellant, the Office will change the
appellant’s APTC/CSR determination accordingly.
o If the ALJ agrees with the Office, the appellant may appeal again to the
U.S. Department of Health and Human Services. However, the
determination by C4HCO will remain in place for the time being.
If the case is one that was coordinated between the Office and HCPF, the
ALJ will decide eligibility for both programs.
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Contact Information
Office of Conflict Resolution and Appeals
Suite 1005
3773 Cherry Creek Drive North
Denver, CO 80209
Phone: 303-590-9640
855-492-2420 (Toll-Free)
Fax: 303-322-4217
Email: Appeals@ap.connectforhealthco.com
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